Download Chronic Idiopathic Constipation

Running head: CAT
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Critical Appraisal Topic
Nutrition Disorder
Mindy Ostrowski
University of Mary
June 20, 2015
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Chronic Idiopathic Constipation
According to Suares & Ford (2011) chronic idiopathic constipation (CIC) is a common condition
affecting the gastrointestinal tract, with an estimated prevalence of between 4% and 20% in crosssectional community surveys (p. 209). Suares & Ford (2011) defines CIC as a functional disorder which
includes infrequent and difficult passage of stools in the absence of any physiological abnormality, the
condition is more common in women, the elderly, and those with lower income and is associated with
reduced quality of life (p. 210).
Case Presentation
M. M. is a 52 year-old woman presenting to the clinic complaining of worsening constipation,
abdominal discomfort and bloating for the past two months. She states that her symptoms began two
months ago when she began working the pm shift versus her previous day shift schedule. She reports that
she has been having only 1-2 spontaneous bowel movements per week. Self-treatment with over the
counter laxatives, (specifically senna products) initiates the urge to defecate, but also causes excessive
straining upon defecation. Patient is a healthy 52 year-old women with a negative past medical history.
Her current medications include a multi-vitamin and fish oil.
Clinical Question in PICO Format
In adults with chronic idiopathic constipation (CIC), which treatment provides better symptom
control: utilization of dietary fiber or pharmacological interventions in addition to dietary fiber?
Scholarly Articles
Attaluri A, Donahoe R, Valestin J et al. Randomized clinical trial: dried plums (prunes) vs. psyllium for
constipation. Aliment Pharmacol Ther 2011;33:822–8.
Ford AC, Suares NC. Effect of laxatives and pharmacological therapies in chronic idiopathic
constipation: systematic review and meta-analysis. Gut 2011; 60: 209–18.
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Summary and Appraisals of Key Evidence
Article One
This article was evaluated based on the Evan’s hierarchy of evidence (Spector, 2010). To address
the varying strengths of different research designs, four levels of evidence are proposed: excellent, good
fair and poor. This study, using Evans hierarchy of evidence, received a level of good (Spector, 2010).
The study notes randomizations but there are notations of bias. This was a prospective RCT aimed to
assess and compare the effects of dried plums and psyllium in patients with chronic constipation. Subjects
were enrolled in an 8-week double blind, randomized cross-over study. Subjects received either dried
plums (50 g or 6gm/day of fiber) or psyllium (11g or 6gm/day of fiber) for three weeks. Subjects
maintained a stool and daily symptom diary. The mean age of the subjects were 38 years of age ranging
from 18-72. The primary outcome was measurement of the effect of treatment on the mean number of
(complete spontaneous bowel movements). The results of the study elicited that the mean number of
CSBM/week was significantly higher during dried plum treatment than during psyllium treatment, dried
plums produced softer stool when compared to psyllium. Stool consistency score was higher with dried
plums when compared to baseline and when compared to psyllium. The weakness of the study is in the
significant overestimation of BM’s by constipated patients. The nature of the study is unblended;
therefore, there may have been a higher degree of responder bias.
Article Two
This article was also evaluated based on the Evan’s hierarchy of evidence. According to this tool,
this article received a level of excellence since it was a systematic review of the literature (Spector, 2010).
The validity has a strong representation related to being a systematic review. The objectives of the study
were to evaluate the efficacy of soluble and insoluble fiber supplementation in the management of chronic
idiopathic constipation. MEDLNE, EMBASE, and Cochrane Central Register of Controlled Trials were
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searched in July or September, 2010, with no language restrictions, search terms were reported. The
bibliographies of identified studies were hand searched, as were relevant conference abstracts published
between 2002-2010. Eligible articles were RCT’s evaluating the efficacy of soluble and insoluble fiber
for the management of idiopathic constipation, in Adults. The outcome data were extracted, by two
independent reviewers; according to the intention-to-treat principle (all drop outs were considered
treatment failures). The result of the study was represented in a narrative synthesis. Six RTCs were
included (368 participants) Compared to the placebo, soluble fiber had greater improvements in
outcomes. This review concluded that soluble fiber could aid in the management of chronic idiopathic
constipation, but the data for insoluble fiber was conflicting, and better evidence was needed for both
types of fiber. The limitations of the evidence include time; last searches were (2010) and further
evidence may be available.
Clinical Bottom Line/Implications for Practice
In summary of the findings, there may be some benefit and little risk of serious adverse events, increasing
dietary fiber or the addition of fiber supplements seems a reasonable initial strategy in the management of
CIC patients. Patients may enjoy improvements in bowel movement frequency and consistency.
According to Suares & Ford (2011) “Effects on other symptoms commonly reported by CIC patients such
as abdominal pain or bloating are more variable. Non-evidence based but practical advice on initiating
therapy with fiber supplements includes starting at a nominal dose and slowly titrating up as tolerated
over the course of weeks to a target dose of 20–30 g of total dietary and supplementary fiber per day. It is
also reasonable to recommend clearing hard stool with an osmotic laxative before initiating fiber therapy,
which may avoid cramping pain” (p. 216). Occasionally, patients will experience marked worsening of
constipation related symptoms with fiber. When this occurs, there are some data to suggest that
significantly delayed colon transit or dyssynergic defecation might be present (Suares & Ford, 2011). The
authors stated that there is a lack of high quality evidence to support the national and international
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guidelines that recommend fiber in the early management of constipation, large, rigorous RTCs were
needed to investigate the efficacy of fiber in managing chronic idiopathic constipation.
References
Attaluri A, Donahoe R, Valestin J et al. Randomized clinical trial: dried plums (prunes) vs. psyllium for
constipation. Aliment Pharmacol Ther 2011; 33:822–8.
Ford AC, Suares NC. Effect of laxatives and pharmacological therapies in chronic idiopathic
constipation: systematic review and meta-analysis. Gut 2011; 60: 209–18.
Spector, N. (2010). Evidence-based nursing regulation: a challenge of regulators. Journal of Nursing
Regulation, 1(1), 30-36.